WHO: Plague – Democratic Republic of the Congo

Three Types of Plague -   Credit CDC

 

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Last summer, in WHO WER: Plague Around The World, we looked at a WHO WER (Epidemiological Weekly Record) review of the 2017 Madagascar Plague outbreak which saw hundreds of confirmed and probable cases.

Globally, a couple of thousand plague cases are reported each year, mostly in rural areas of Africa, Asia, and South America, with Madagascar the hardest, and most consistently hit region.

Bubonic Plague (Yersinia Pestis) - carried by rats, squirrels, and other small rodents, and transmitted by fleas - sets up in the lymphatic system, resulting in the tell-tale buboes, or swollen lymph glands in the the groin, armpits, and neck. 

Less commonly Pneumonic Plague may develop, when the infected individual develops a severe pneumonia, with coughing and hemoptysis (expectoration of blood), which may spread the disease by droplets from human-to-human.

Modern medicine, particularly the advent of effective antibiotics, makes plague far less fearsome than it once was, but Madagascar's recent epidemics, and a large 1994 India outbreak that infected more than 5,000 people (see WHO Summary), show that large urban outbreaks are still possible.

 

The US reports an average of seven human plague cases each year (range: 1–17 cases per year) - mostly bubonic - and almost always in the Western states. The last major urban outbreak of plague in the United States occurred in 1924-25 in Los Angeles.

CREDIT CDC

Overnight the World Health Organization is reporting on a new outbreak of plague in the Democratic Republic of Congo which began in June.  This outbreak is just the latest challenge for the DRC, and comes on top of COVID-19, an ongoing Monkeypox epidemic, and recurrent outbreaks of Measles and Ebola. 

Plague – Democratic Republic of the Congo

Disease outbreak news

23 July 2020

The health zone of Rethy in Ituri province, the Democratic Republic of the Congo, has seen an upsurge of plague cases since June 2020. The first case, a 12-year-old girl, reported to a local health centre on 12 June experiencing a headache, fever, cough, and an enlarged lymph node. She died on the same day and further deaths from the community due to suspected cases of plague were subsequently reported.

From 11 June though 15 July, six out of 22 health areas have been affected within Rethy health zone (11 villages), with a total of 45 cases including nine deaths (case fatality rate: 20%). All nine (9) cases who died presented with signs of headache, high fever, and painful nodes; four (4) out of the nine (9) cases had cough.

The health zone team carried out an investigation resulting in five positive rapid diagnostic tests (RDTs). Nine additional samples were taken and shipped to the Institut National de Recherche Biomédicale (INRB) laboratory in Kinshasa. Of the 45 cases reported, two showed signs of septicemic plague; all the other cases were diagnosed as having bubonic plague. According to the available information, it is likely that all three types of plague clinical presentation (bubonic, septicemic and pneumonic) are present.

The distribution by sex shows 58% (26/45) are male and 93% (42/45) are greater than five years old. Of the 45 cases reported, nine including four who died, had cough among the symptoms - a sign indicating a potential progression from bubonic plague to pulmonary plague. This was specifically noticed among the deceased.

Plague is endemic in Ituri province. Since the beginning of 2020, Ituri Province has reported a total of 64 plague cases and 14 deaths (CFR:21.8%) in five health zones, namely Aungba, Linga, Rethy, Aru and Kambala health zones. This compares against 10 cases and 5 deaths (lethality 50.0%) during the same period in 2019, all in a single zone.

The current COVID-19 epidemic affects seven out of 26 provinces in the country. Ituri has also reported cases of COVID-191 that may further interrupt response activities due to lockdown. These are in addition to long standing public health response challenges identified in the region, including a lack of resources and insecurity. Although it has been reported that there is no significant impact of the COVID-19 context on activities taking place in this area, there is limited information available on the current access to health care. This includes whether or not there is a need for the population of Ituri to seek care in Uganda, as well as the availability of human resources, drugs, and personal protective equipment (PPE). Furthermore, the reference laboratory in Bunia, Ituri province is currently not functional, which might delay the confirmation of suspected cases and response efforts.

Public health response

• A national rapid response team (RRT) has been deployed to the affected health zone to conduct an outbreak investigation and implement initial response activities.
• UNICEF is on the ground responding to the humanitarian situation at Bunia, working on community engagement and safe and dignified burial practices.
• The WHO guideline for plague, including case definitions, has been disseminated to health facilities to improve the detection of cases.
• The WHO is supporting plague endemic areas with surveillance, investigation of cases, and training of health workers and community relays in the prevention, early detection and case management of plague.
• Doxycycline prophylaxis has been administrated to the listed contacts.
• Intra-household spraying with deltamethrin has been used in some villages.
• Safe and dignified burials (SDB) have been performed by the health district team.
• Sensitization of the population on plague prevention measures in the affected villages through local radio.

WHO risk assessment

Infection with plague can cause severe disease resulting in high mortality in humans, particularly if not identified early. Plague can exhibit in three forms: bubonic, septicemic and pneumonic. If untreated, bubonic plague can evolve to pneumonic plague. Early diagnosis and treatment are essential for survival and reduction of complications.

Rethy health zone is endemic for plague and regularly registers cases of enzootic variants of Yersinia pestis, in much of the wild rodent population. Its first outbreak was reported in February 2020 with cases imported from Linga health zone, based in the Godjoka health area.

On the security level, there are reports of atrocities and violence linked to the militia CODECO which continues to impact the population of this territory (Djugu and its surroundings). There have been mass population displacements within Djugu and Mahagi Territories. Currently, the Rethy Health Zone has received approximately 112 714 internally displaced persons (IDPs), most of whom have come from the Jiba and Linga Health Zone. The growing insecurity impacts traffic flow between the villages and the willingness of the population to either stay or work in that area. There has also been a deterioration of water, hygiene and sanitation conditions in the reception areas and in the IDP sites.

The early detection and reporting of the current outbreak by healthcare workers demonstrate that a functioning surveillance system is in place. Ituri province had a reference laboratory in Bunia which is no longer functional. The Institut National de la Recherce Biomedicale (INRB) laboratory based in Kinshasa/DRC has the ability to conduct laboratory testing for suspected cases. However, delays in shipping samples from Rethy to Bunia and then to Kinshasa, and delays in testing in Kinshasa INRB due to high workload and backload related to COVID-19 samples to be tested, might jeopardize the surveillance and response. Ongoing efforts are required to ensure that any other cases are promptly detected, isolated, and investigated to avoid the establishment of local transmission.

The risk at national level is considered to be moderate given: the evolution of the current situation is in danger of deteriorating rapidly (case fatality rate: 20%), the notification of cases of pulmonary plague, the challenges with the surveillance system and delays between sample collection and laboratory confirmation, and the volatile security situation and the existence of other epidemics in progress in the country which prevents the setting up of a more comprehensive response. Furthermore, the health zone currently does not have enough PPE, body bags and materials needed for decontamination. Malteser International, an NGO that supplies the health zone with drugs, has had difficulty getting the products into the zone because of insecurity on the RN27 road.

The principles of control are known and have been implemented (early treatment with the recommended antibiotics, isolation of the pneumonic cases, chemoprophylaxis given to the close contacts of the latest ones, rodent and flea control, safe and dignified burials, and the prevention of nosocomial transmission) but the means are limited and the health system is unable to manage the cases in the most appropriate way. The antibiotics used for the treatment of the cases are Doxycycline, Ciprofloxacin and Cotrimoxazole. For the pulmonary or septicemic form case, Gentamycin was administrated. The lack of laboratory confirmation is worrying but the use of rapid diagnostic tests (RDT) on the field ensures a minimum of confirmation among the suspected cases. The RDTs are especially reliable to confirm bubonic plague suspected forms.

The risk at regional level is considered low since the epidemic seems to be contained in the Rethy health zone and that it is an isolated region. The risk is considered low globally.

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